Registration Requirements - Pendergast Elementary School District
Anuncio
Registration Requirements You Will Need the Following for Registering: *Completed Enrollment packet for each student enrolling (Includes In-District Transfers)* 1. Parents/Guardians must be present and provide a government issued photo identification. 2. Proof of Residency Main: (must be current within the last 30 days) ______ Mortgage Purchase Statement or Rental/Lease Agreement ______ SRP/APS Electric Bill displaying parent name and home address ______ Southwest Gas Bill displaying parent name and home address ______ Water Bill displaying parent name and home address *District guidelines for Proof of Residency have been established and will be adhered to for all students. Proof of Residency documentation must be renewed each year. And 3. Proof of Residency Secondary: (must be current within the last 30 days) ______Telephone Bill displaying parent name and home address ______Doctor’s Bill displaying parent name and home address ______Bank or Credit Card Statement displaying parent name and home address ______Car Insurance displaying parent name and home address 4. Notarized Form Please Note: If living with another family in the district, a Notarized Form must be completed along with one Proof of Residence listed in #1 from the resident. Parent/Guardian must also provide Proof of Residence within 30 days of student start date. 5. Guardianship Paperwork (If Applicable) Please Note: The assigned legal guardian must register the child, and provide court appointed custody documentation. 6. Immunization Records ______Must have up to date records 7. Birth Certificate ______ Must be a Certified Birth Certificate from the Vital Statistics of the state child was born in, not a hospital certificate 8. Withdrawal Form and/or Report Card from previous school Complete Registration Central Registration cannot process faxed or mailed enrollment packets; parent(s)/guardian(s) must complete the enrollment process in person. Only completed registrations will be accepted. Central Registration Contact Information 3841 N. 91st Ave. Phoenix, AZ 85037 Open: Monday- Friday 8:00 a.m. to 4:00 p.m. Phone: (623) 772-2302 Fax: (623) 872-8568 http://www.pesd92.org Updated 7/1/14 PENDERGAST ELEMENTARY SCHOOL DISTRICT #92 STUDENT ENROLLMENT FORM /REGISTRO DE ALUMNOS FOR OFFICE USE ONLY: PARA EL USO DE LA OFICINA UNICAMENTE: CTD# 070492 School#:__________ SAIS #:_____________________ Student#: _______________ Date Entered in SMS: ____________ Entry Code:________ First Day of Attendance:___________ Language Code:________ Previously Attended Pendergast District: Yes [ ] No [ ] Special Health Conditions: _____________________________ Agricultural Work in Last 3 Years: Yes [ ] No [ ] Doubled Up: Yes [ ] No [ ] Current Program Information: Special Education: Yes [ ] No [ ] Speech: Yes [ ] No [ ] ELL: Yes [ ] No [ ] Gifted: Yes [ ] No [ ] 504 Plan: Yes [ ] No [ ] Transportation: Yes [ ] No [ ] Student Information/ Información de los Estudiantes ____________________________________________________________________ __________________________________________________ ______ ___ _____________________________________ ___ ____________ Student Legal Last Name /Apellido Legal Student Legal First Name / Primer Nombre Legal Middle Name /Segundo Nombre Sex / Sexo _____________________________________________________________________________ ______________________________________________ _______________________________ Address/ Domicilio City / Ciudad Zip Code/ Codigo Postal __________________________ Home Phone / Telefono ________________________ Current Year Grade/ Grado Actual Yes [ ] No [ ] Unlisted/ Privado ______________________________________ Birth City, State, Country/ Ciudad Natal, Estado, País ___________________________________________________________ Month Day Year________ Birthdate/ Fecha de Nacimiento ________________________________________ Last School Attended, State / Escuela Anterior, Estado # Years Attended/# de Años que Asistió __________________________ Present Age/ Edad Actual Yes/Si [ ] No [ ] Grade/ Grado_________ Has Student Ever Been Retained? ¿Ha sido el Alumno Alguan Vez Reprobado? Ethnicity/ Etnicidad: Is the student Hispanic ?/¿Es El Estudiante Hispano o? (Choose only one/Elija una respuesta solamente)? Yes/Si [ ] No [ ] Race/ Raza: What is the Student’s Race?/¿Cual Es La Raza Del Estudiante? (Choose one or more/Elija una o más respuestas)? _____ American Indian/ Alaska Native/ Indígeno Americano o Nativo de Alaska _____ Asian/ Asiatico _____ Black/African American/ Afro Americano _____ Native Hawaiian/ Other Pacific Islander/ Hawaiano Indígeno U Otras Islas Del Pacifico _____ White/ Blanco What is the primary language used in the home regardless of the language spoken by the student? _______________________________________________ ¿Cuál es el idioma que se habla principalmente en el hogar sin importar el idioma que habla el estudiante? _______________________________________________ What is the language most often spoken by the student? _______________________________________________ ¿Cuál es el idioma que el estudiante habla con mayor frecuencia? _______________________________________________ What is the language that the student first acquired? _______________________________________________ ¿Cuál fue el primer idioma que aprendió el estudiante? _______________________________________________ Is student receiving ELL support services? Yes/Si [ ] No [ ] #of Years __________ ¿Está recibiendo los servicios de apoyo del ELL? # de Años _________ Does student have refugee status? Yes/Si [ ] No [ ] #of Years __________ ¿Tiene una categoría de refugiado el alumno? # de Años _________ Is the student receiving Special Education Services? Yes/Si [ ] No [ ] ¿Está el alumno recibiendo los servicios de educación especial? Do you have your child’s IEP paperwork? Yes/Si [ ] No [ ] ¿Tiene el IEP (plan de educación individual) presente? Is the student currently serving or being recommended for long term suspension? Yes/Si [ ] No [ ] ¿Está actualmente el alumno suspendido o en trámites para una suspensión de largo plazo? Is the student currently expelled or being recommended for expulsion? Yes/Si [ ] No [ ] ¿Está actualmente el alumno expulsado o en trámites de expulsión? Family Information/ Información de la Familia: Child lives with: EL alumno vive con: Mother Madre Full Name Nombre Completo Father Padre Step Mother Madrastra Step Father Padrastro Business Phone Teléfono del trabajo Foster Mother Madre Adoptivo Cell Phone Teléfono Celular Foster Father Padre Adoptivo Home Phone Teléfono de la casa Guardian Tutor Other: _______________ Otro E-Mail Address Correo electrónico Mother/Madre Father/Padre Stepparent/ Padrastros Guardian/Tutor If separated or divorced, who has legal custody?/ Si esta separado (a) o divorciado (a), ¿Quien tiene la custodia? N/A [ ] _________________________________________ Copies of legal custody papers furnished?/ ¿Se proporcionaron los documentos legales de la custodia? Yes/Si [ ] No [ ] N/A [ ] Does the other parent have visitation rights? ¿Tiene derechos legales de vista el otro padre? Yes/Si [ ] No [ ] N/A [ ] Emergency Contact Information/ Información de Contacto de Emergencia The following people have permission to pick up my child and may be notified in an emergency: Las siguientes personas tienen mi permiso para recoger a mi hijo(a) y pueden ser notificadas en caso de emergencia: Name/ Nombre Relationship to Child Home Phone Business/Cell Phone Parentesco con el Tel. de casa Tel. Trabajo/celular niño Sibling Information/ Información Sobre Hermanos Please list all siblings attending this school: Por favor anote a los otros hermanos(as) que asisten a ésta escuela: Name Nombre Birthdate Fecha de Nacimiento Grade Año As the Parent/Legal Guardian of the student, I attest that I am a resident of the State of Arizona and submit documentation that displays my name and residential address or physical description of the property where the student resides. By signing this document I am stating the information supplied is true and accurate. Como Padre/Guardián del alumno yo atestiguo que soy residente del estado de Arizona y he presentado documentación que demuestra mi nombre y domicilio o descripción física de la propiedad de donde vive le alumno. Al firmar este documento estoy declarando que la información brindada es verdadera y correcta. X_________________________________________________________________________________________ Parent/ Guardian Signature /Firma Del Padre /Tutor Date/ Fecha Revised 6/14 -PESD State of Arizona Department of Education Office of English Language Acquisition Services Primary Home Language Other Than English (PHLOTE) Home Language Survey (Effective April 4, 2011) These questions are in compliance with Arizona Administrative Code, R7-2-306(B)(1), (2)(a-c). Responses to these statements will be used to determine whether the student will be assessed for English Language Proficiency. 1. What is the primary language used in the home regardless of the language spoken by the student? __________________________________________________________ 2. What is the language most often spoken by the student? _______________________ 3. What is the language that the student first acquired? __________________________ Student Name ______________________________________ Student ID __________________ Date of Birth _____________________________________ SAIS ID ______________________ Parent/Guardian Signature __________________________________ Date _________________ District or Charter ______________________________________________________________ School _______________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------Please provide a copy of the Home Language Survey to the ELL Coordinator/Main Contact on site. In SAIS, please indicate the student’s home or primary language. 1535 West Jefferson Street, Phoenix, Arizona 85007 • 602-542-0753 • www.azed.gov/oelas PENDERGAST SCHOOL DISTRICT #92 STUDENT HEALTH HISTORY VOLUNTARY Name___________________________________________Date of Birth_______________________________ Last First Middle Month Day Year Completion of this form is voluntary. However, the following information may be helpful in assessing a child’s health/learning. This information may be shared with school staff who have a need to know in order to protect your child. Has this child ever had any of the following? If “yes”, please give age at the time. Age Age Yes____ No____ Allergies ____ Yes____ No____ Hemophilia ____ To What?_________________________ Yes____ No____ Hepatitis ____ Yes____ No____ Arthritis ____ Yes____ No____ High Blood Pressure ____ Yes____ No____ Asthma ____ Yes____ No____ Kidney Disease ____ Yes____ No____ Attention Deficit Disorder ____ Yes____ No____ Migraines ____ Yes____ No____ Cerebral Palsy ____ Yes____ No____ Rheumatic Fever ____ Yes____ No____ Chicken Pox ____ Yes____ No ____Seizures ____ Yes____ No____ Curvature of Spine ____ Yes ____No ____Skin Rashes ____ Yes____ No____ Diabetes ____ Yes____ No____ Stomach Problems ____ Yes____ No____ Eczema ____ Yes____ No____ Urinary Tract Infections ____ Yes____ No____ Frequent Ear Infections ____ Yes____ No____ Heart Disease ____ Other: __________________________________ Yes____ No____ Is child taking medicine? __________________________________ Name of Medicine__________________ Yes____ No____ Has this child ever had surgery? Yes____ No____ Ever had a serious accident or injury? Yes____ No____ Does this child wear glasses? Reading?______ Distance?_____ Yes____ No____ Have other vision difficulties diagnosed by a professional? Yes____ No____ Have any speech difficulties diagnosed by a professional? Yes____ No____ Have any hearing difficulties diagnosed by a professional? Yes____ No____ Wear a hearing aide(s)? Yes____ No____ Has this child ever had tubes put in his/her ears? Yes____ No____ Does this child have tubes in his/her ears now? Yes____ No____ Would you like to discuss any of this health history with the school health personnel? Please list phone # and best time to be reached:_____________________________________ Physician’s/Clinic Name_____________________________________________________________________ Please explain any “Yes” answers / or provide additional information you may feel may be useful for the school health personnel: (Be sure to list any medications your child is taking.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________ Signature of Parent/Guardian _____________________________ Date Pendergast Student Residency Questionnaire Name of School _______________________________________________________________ Name of Student ______________________________________________________________ Last First Middle Birth Date ____/____/____ Age: ____ Sex: Male Female Grade: _________ 3. Is the student under refugee status? Yes ____ No ____ If yes, Country __________________ Effective Date ________________ 4. Was student born outside of the US? Yes ____ No ____. If yes, Country ____________________________ If born outside of US, are the parents in the US Military? Yes ____ No ____ List all schools attended for the past 3 years. School Year Grade School Name City State Country This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to receive. 1. Is your current address a temporary living arrangement? Yes ____ No ____ 2. Is this temporary living arrangement due to loss of housing or economic hardship? Yes ___ No ___ If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here. Where is the student presently living? (Circle one option) • • • • • In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations such as a car, park, or campsite Name of Parent(s)/Legal Guardian(s) ______________________________________________________________ Address ________________________________________________________ Zip ________ Phone _____________ Signature of Parent/Legal Guardian _____________________________________________ Date ____________ Office personnel: If both questions are marked yes, please make a copy and send to Educational Services, attention Lourdes “Lulu”Rood Will your child need transportation if it is determined that they qualify for the McKinney-Vento Act? Yes No PENDERGAST ELEMENTARY SCHOOL DISTRICT #92 AUTHORIZATION AND PERMISSION TO RELEASE MEDICAL and EDUCATIONAL Records Student:___________________________ DOB:_________________ Grade:_______ Previous School Attended:________________________________________________ Address (Previous School):________________________________________________ City/State/Zip (Previous School):___________________________________________ Phone Number (Previous School): __________________________________________ Fax Number (Previous School):_____________________________________________ In compliance with the Family Education Rights and Privacy Act of 1974, I authorize the release of my child’s school records, including gifted, educational, medical, social or special education information to the Pendergast Elementary School District. Signature: ___________________________________________ Date: ____________ Relationship to Child:____________________________________________________ PLEASE SEND RECORDS, EXCEPT SPECIAL EDUCATION RECORDS, TO THE FOLLOWING SCHOOL: [ ] Amberlea 8455 W. Virginia Ave. Phoenix, AZ 85037 (623) 772-2900 Fax: (623) 594-2786 [ ] Canyon Breeze 11675 W. Encanto Blvd. Avondale, AZ 85392 (623) 772-2610 Fax: (623) 478-9912 [ ] Copper King (623) 772-2580 Fax: (623) 872-7769 [ ] Desert Horizon 8525 W. Osborn Rd. Phoenix, AZ 85037 (623) 772- 2430 Fax: (623) 873-4691 [ ] Desert Mirage 8605 W. Maryland Ave. *OHQGDOH, AZ 85305 [ ] Garden Lakes 10825 W. Garden Lakes Pkwy. Avondale, AZ 85392 (623)772- 2520 Fax: (623) 877-9545 [ ] Pendergast 3800 N. 91st Ave. Phoenix, AZ 85037 (623) 772-2400 Fax: (623) 877-9591 [ ] Rio Vista 10237 W. Encanto Blvd. Avondale, AZ 85392 (623) 772-2670 Fax: (623) 478-1972 [ ] Sonoran Sky 10150 W. Missouri Ave. Glendale, AZ 85307 (623) 772-2640 Fax: (623) 772-1005 [ ] Sunset Ridge 8490 W. Missouri Ave. Glendale, AZ 85305 (623) 772-2730 Fax: (623) 877-4935 [ ] Villa De Paz 4940 N. 103rd Ave. Phoenix, AZ 85037 (623) 772-2490 Fax: (623) 877-8977 [ ] Westwind 9040 W. Campbell Ave. Phoenix, AZ 85037 (623) 772-2700 Fax: (623) 772-8464 10730 W. Campbell Ave. Phoenix, AZ 85037 (623) 772- 2550 Fax: (623) 872-8401
